Many Medicare patients with new episodes of low back pain receive care inconsistent with current guidelines – including high use of opioids and advanced imaging tests, reports a study in the February issue of Medical Care. The journal is published in the Lippincott portfolio by Wolters Kluwer.
Opioids are prescribed to nearly one-third of older adults with “new
and persistent” Low Back pain – in most cases without trying
guideline-recommended pain medications or physical therapy, according to
the new research by Dan Pham Ly, MD, MPP, of Harvard University. He
comments, “This study raises concerns about excessive use of low-value
and potentially harmful treatments for the common problem of LBP in
older adults, with under-use of evidence-based, guideline-recommended
treatments.”
Many Medicare Patients Don’t Receive Evidence-Based Treatments for New LBP
The study used Medicare claims data on more than 162,000 older adults
with new LBP from 2011 through 2014. About 70 percent of patients were
women; average age was approximately 77. None had received previous
opioid treatment. The analysis included information on multiple visits
for LBP over the course of a year, providing data on the timing and
sequence of care.
Over half of patients (54 percent) made only one healthcare visit for
LBP. That’s consistent with evidence that many new episodes of LBP are
self-limiting. As stated in the current
American College of Physicians guidelines, most patients with LBP “improve over time regardless of treatment.”
Advanced imaging studies – computed tomography (CT) or magnetic
resonance imaging (MRI) scans – were used in about 15 percent of
patients overall, and 29 percent of those with two or more LBP visits.
In about half of cases, CT or MRI scans were performed within six weeks.
That’s contrary to an
American Academy of Family Physicians statement that most patients don’t need advanced imaging studies for initial evaluation of LBP.
Opioids were prescribed to about one-fourth of patients overall,
including one-third of those with two or more LBP visits. In contrast,
LBP guidelines suggest that other pain relievers – including
nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen or
ibuprofen – should be tried before opioids.
Physical therapy was prescribed to only 11 percent of patients
overall and 17 percent of those with two or more visits. Evidence
suggests that early use of physical therapy can avoid the use of opioids
in patients with LBP.
Most patients treated with opioids had not received a prescription
NSAID or physical therapy. Chronic opioid use developed in about one
percent of patients overall, and nearly two percent of those with two or
more visits.
Low back pain is a common reason for healthcare visits – in a given
year, about ten percent of people will develop a new episode of LBP.
Studies examining trends in LBP treatment found increasing use of
opioids, and decreased use of NSAIDs, up to 2010. The new analysis
focused on more recent patterns in evaluation and treatment of LBP in
Medicaid patients, including data on repeated visits over one year.
“Many patients who develop new LBP receive guideline non-concordant
care such as early advanced imaging and opioids before other modalities
like PT and prescription NSAIDs,” Dr. Ly writes. At least in the first
half of the past decade, one-third of patients making two or more LBP
visits received opioids – often without having tried other recommended
treatments.
Dr. Ly calls for future studies examining barriers to
guideline-recommended treatments for LBP in older adults – particularly
physical therapy and NSAIDS. He also points out that pain management can
be challenging in older adults, highlighting the need for studies to
compare the safety and effectiveness of medication options.
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Click
here to read “Evaluation and Treatment Patterns of New Low Back Pain
Episodes for Elderly Adults in the United States, 2011-2014.”
DOI: 10.1097/MLR.0000000000001244
https://www.eurekalert.org/pub_releases/2020-01/wkh-flb012320.php
